WETTING BEHAVIOR
Youth come to foster care with a number of behaviors that are often difficult to understand and difficult to treat. An example is various forms of wetting or urinary behaviors. These behaviors are especially difficult for foster parents to manage and can often be a reason why a placement will terminate.
DESCRIPTION OF THE PROBLEM:
It is amazing the various forms that wetting behavior may be displayed. I have worked wetting behaviors which include: bed wetting; wetting self; urinating in containers such as jars and vases; urinating on clothes that are placed in a pile; urinating in dresser drawers; urinating in closets; urinating in corners of rooms; urinating in a vehicle when the vehicle was not in use; urinating down furnace vents; and wetting in secondary sleeping situations. (Youth would sleep in a fort he constructed and wet in the fort.)
RULE-OUTS:
Youth that are displaying consistent wetting behavior, past an appropriate development age, should always be evaluated by a pediatrician who may make additional medical referrals for evaluation. Medical evaluation should be completed prior to the development of behavior/emotional interventions.
A THOROUGH UNDERSTANDING OF THE CHILD’S HISTORY:
If a foster youth is in placement with wetting behavior, attempt to secure the following information:
- Nature of the wetting: patterns, settings where the child wets, what escalates/diminishes the wetting;
- Has the child been medically and psychiatrically evaluated for the wetting behavior and what were the results?
- Was the youth ever toilet trained?
- Has the child experienced childhood trauma; specifically sexual abuse?
- Was the child neglected and what was the nature of the neglect;
- Does the child have the intellectual ability to learn toileting?
- Is there a behavioral and/or emotional connection to the wetting that can be identified?
- Has there been any psychological testing or therapy that comments on the wetting behavior from a causation or intervention perspective?
- What interventions have been tried in responding to the wetting behavior and what were the results?
- What has been the child’s caregiver’s response to the wetting?
- Is there a history of wetting in the youth’s family? If so, at what age did the wetting behavior stop?
- Are there other health conditions that impact the wetting?
- Is the youth on medication that can impact wetting?
It is our hope that the history collected will assure that the youth has received the proper medical and psychological evaluation for the wetting behavior. It is my hope that securing and reviewing this information will offer the foster parent and social worker insight into future interventions and avoidance of repeating past failed interventions. It is important that foster parents have information on wetting behavior so they are prepared in consistent manners by which to respond.
WHY WETTING BEHAVIOR:
There are probably a number of reasons why youth wet. We know that a common symptom of individuals that have been traumatized is that they develop a hyper-sensitivity to reminders of the trauma. These reminders can be smells, sensory feelings, symbols that remind them of the experiences. We also know that victims of trauma develop ingenuous ways to defend themselves against the re-occurrence of trauma. Additionally, we know that child neglect impacts skill development on multiple levels creating a situation where a child’s age and their developmental age become distorted. We also know that being a victim of childhood physical abuse generally creates an internal system of anger that is often generalized to others. In foster care, this is generally projected unto the foster parents. And finally, with few exceptions, youth in foster care long to be with their own families simply because they love them and miss them. In these contexts, wetting behavior can be seen as having purpose and understandable.
GROUPINGS OF WETTING BEHAVIORS:
In discussing the case histories of youth that wet, I have identified the four following groupings of wetting behavior: protective/anxiety; anger/control; reminiscent of home; and symptoms of neglect. Realistically, there is probably not a youth grouping for wetting that exists in a pure form. Additionally, my identification of these grouping is based on working hypotheses based on foster youth’s histories and behaviors. The case histories below are composite histories of youth and not specific to any one youth thus preserving confidentiality.
INTERVENTIONS:
Protective/anxiety
Case history:
Carrie is a 10 year old female referred to treatment foster care by County Social Services. She was removed from her home because of being a victim of sexual abuse. The abuse was perpetrated by a live-in boyfriend who is awaiting trial on the charges. The sexual abuse was confirmed medically. Carrie’s mother is addicted to meth. Her whereabouts are unknown currently. The home was reported to have been occupied by a number of individuals where meth was reported to have been used freely and often. Carrie has recently begun seeing a therapist and is being treated with an anti-depressant that targets depression and anxiety. She was in a County foster home. In the County foster home, it was noted that Carrie was urinating in jars at night and at times wetting her bed. There had been some day time wetting but it is generally not a consistent problem. She has been in a treatment foster care placement for approximately 4 months. The day time wetting has decreased as Carrie has adjusted to her new home and new school. She remains a compliant, quiet girl who is hyper-vigilant; especially when encountering new people or situations.
Interventions:
Try to make Carrie’s night time routine as safe and predictable as possible. Attempt to find out from Carrie if she is afraid to get out of her bed at night and if this contributes to her wetting. Have her select the proper lighting for her room. Provide her with bedtime stories that are positive and comforting. If at all possible, do not have her room share. Have her use the toilet before she goes to bed. Explain to her that the bathroom light will be left on so if she needs to use the bathroom it will be lighted. Provide her with a flashlight. Review the pathway to the bathroom to assure it is safe and make any adjustments that may be needed. If a program is in place where Carrie is awakened to use the bathroom at night, make certain the routine is safe for her. Attempt to not make changing of wet sheets punitive in any way. Have extra pajamas available. Reinforce, in a private respectful way, consistency in being dry. Attempt to identify with Carrie symbols that make her feel safe and secure. (Example: special stuffed animal) Attempt to identify simple calming techniques. If these interventions fail, consider using a container that is normalized and sanctioned in Carrie’s room to be used for evening urination. (Example, a camping porta-potty that is emptied in the morning.)
Anger/control
Case History:
Jenna is an 11 year female referred to treatment foster care because of her inability to be maintained in “regular” foster care”. She is a youth who was physically abused and neglected by her primary care givers. She has been involved in several kinship care placements, all of which failed. She is a child who appears always on guard and easily irritated. She is being treated with two medications, one that focuses on attention issues and one that focuses on mood stability. She does not do well in school, resists directives, fights with peers and argues with her teachers. She does best in the resource room where expectations are clear but not based on group conformity. She is active and enjoys physical activity. She has developed the ability to self-impose a time out. The two options that she utilizes are drawing or going to the gym where she involves herself in a physical activity. Generally she can re-involve herself after these time-outs. It is predictable when she is most at-risk to act-out; in the morning, when first coming to school and the time surrounding lunch. She is involved in individual therapy but the therapist acknowledges that establishing a therapeutic relationship with Jenna has not occurred because of Jenna “not wanting to see a counselor”. On several occasions, Jenna has taken her clothes, placed them in a pile and urinated on them. She does not experience daytime or evening wetting. These incidents seem connected with a time period when the placement has been going well and a seemingly insignificant event occurs that results in Jenna becoming angry; especially with the foster mother. Jenna seems to enjoy being “caught” for urinating on her clothes especially if she notes that her foster parents are angry or hurt.
Interventions:
Shift the therapeutic attention away from Jenna and assist the foster parents with a number of interventions. Help the foster parents identify signs when Jenna maybe becoming uncomfortable with the closeness of the home. Create a system where the foster parents “step back” in their relationship to Jenna until she becomes more tolerant. Create a “menu” of activities that Jenna can conduct that are energy expending and incorporate them into the home routine in order to defuse chronic anger. Study what has worked in the school and attempt to incorporate in the home if appropriate. Search for social outlets that maximize her skills physically. Design consequences that respond to the urinating. (cleaning the area, clothes, restricting outside privileges etc) Identify the wetting as a manner by which to distance and angrily reject others.
Reminiscent of home
Case History:
Joey is a 14 year old who has recently been removed from his parents’ home and placed in foster care for reasons of physical, medical and educational neglect. Both of Joey’s parents are dually diagnosised, suffering from a combination of developmental disabilities and psychiatric disorders. Additionally they are in poor health. The family has received a variety of services inclusive of economic assistance; home health services, homemaker services, parent aide services, CMI and DD case management services. In spite of all of these services, and the best intentions of Joey’s parents, the home remains unsanitary and neglectful. Joey is diabetic and the home health nurse has identified that Joey is not receiving proper nutrition and diabetic care in the home. Additionally, he has been refusing to go to school and not attending. He identifies his reasons for not attending school is that the other students make fun of him because he smells and they call him dumb.
Joey loves his parents deeply. He wants to return home and talks about it consistently with his foster parents, his own parents, his counselor, special ed. teacher and social worker. He has regular visits with his parents, generally accompanied by his social worker. After the visits he cries and isolates himself in his bedroom at his foster home. Although he refuses to admit it, he has been wetting his bed in the evening.
Interventions:
Attempt to establish a number of symbols and objects that can be transferred from Joey’s own home to his current room at the foster home with the assurance that they can remain with him upon his departure from foster care. Objects and symbols can be in the form of pictures and videos of family, toys, security items, blanket, music etc. Attempt to involve the foster parents in the home visits in order to establish a mutual knowledge and an understanding between the homes that is modeled for Joey. Monitor if the visits impact the wetting. Attention on the wetting behavior should take the form of instruction and involve him in learning proper hygiene skills. Make this process visual, concrete and repetitive. Exaggerate positive reinforcement for compliance and reward with concrete rewards that appeal to Joey.
Symptoms of neglect
Case History:
Darwin is a 5 year old recently entering foster care because of parental abandonment. Little is known about his background as his own family was new to the area prior to the child protection intervention. He experiences a number of developmental delays that often indicate child neglect. Darwin is scheduled for a variety of evaluatory appointments in the next month.
Darwin is a very active young man, never seeming to stop. He runs everywhere, yells instead of talks, takes instead of asks, overeats to the point where he becomes ill and has tantrums when matters do not go the way he wanted. However, Darwin can be very loving and engaging given the right circumstances. He does not appear to ever have been toilet trained. He doesn’t seem to experience any discomfort in wetting his pants, or sheets, or anywhere for that matter. His foster father attempted to have Darwin urinate in the toilet, however, he urinated everywhere but in the toilet and seemed bewildered by the experience.
Interventions:
Behavior programming is needed. Begin the process by using the proper clothing and toilet fixtures. Attempt to replicate standard toilet training procedures, however, remember that time passed has reinforced not being toilet trained (pull-ups and potty chair should be considered). If using pull-ups, start the reinforcement process by rewarding when Darwin identifies he is wet. After he is able to identify when he is wet, begin to schedule toileting for Darwin at certain time internals. If possible, review the schedule with a pediatrician and also request input on appropriate medication. Consider seemingly odd toileting engagement games such as throwing cheerios in the toilet and having Darwin “shoot” at them. Include the school and day care in the behavior programming to accomplish consistency. Verbally reward any success, especially when Darwin self initiates any toileting. Monitor fluid intake in the evening. Protect the bed with a plastic mattress cover.
Other Considerations:
It is often necessary to include protective devices in response to wetting such as plastic mattress pads, pulls-ups, polyester sheets, review of medication options, timing devises that signal when a child is beginning to wet. There is consistent improvement in the development of new types of protective bedding and safe interventions for children that wet. Often pediatricians are aware of these products and can offer advice on the latest developments in this area.